INDONESIA DEMOGRAPHIC AND HEALTH SURVEY 1997 HOUSEHOLD SCHEDULE Confidential ZDmr.~IFI~TIO~ I co.E

APPENDIX E
QUESTIONNAIRES

97IDHS
Logo
INDONESIA DEMOGRAPHIC AND HEALTH SURVEY 1997
HOUSEHOLD SCHEDULE
Confidential
ZDmr.~IFI~TIO~
I. PROVINCE

I

co.E

...............

2. R E G E N C Y / M U N I C I P A L I T Y

*).

3. S U B - D I S T R I C T
4. V I L L A G E
5. A R E A ............... U R B A N - 1 .......... RURAL - 2 **)

6. LARGE CITY -1/SMALL CITY -2/TOWN -3/COUNTRYSIDE

-4*)

7, ENL~FS~ATIDNI~REA~HJMBE R
8. IDHS 1997 SAMPLE CODE ..............................

9. MOUEEHOLDNUMEEH ...................................
10. N A M E OF H O U S E H O L D E E A ~

INTERVIEWER VZSITS

i

2

3

FINAL V I S I T

I N T E R V I E W D A T E ......

DATE
MONTH

INTERVIEWER'S

YEAR

NAME..

E ~ - 9

R E S U L T ***) .........

INTERVIEW

N E X T VISIT:

DATE

FINAL RESULT

TIME

T O T A L NO. OF V I S I T

***) R E S U L T CODES:
1 COMPLETED
2 N O H O U S E H O L D M E M B E R AT HOME OR N O COMPETENT
R E S P O N D E N T A T HOME AT TIME OF V I S I T
3 E N T I R E H O U S E H O L D A B S E N T FOR EXTENDED PERIOD
4 POSTPONED
5 REFUSED
6 D W E L L I N G V A C A N T OR ADDRESS N O T A DWELLING
7 D W E L L I N G DESTROYED

8 DWELLING NOT FOUND
9 OTHER
(SPECIFY;

FIELD E D I T O R
NAME

voloco

7

l--

NO, OF HOUSEH O L D MEMBERS
T O T A L EVERMARRIED WOMEN
W O M E N 15-49

~

N U M B E R OF F A M I L Y

[]

RESPONDENT
LINE N U M B E R

DATE

*)
**)
***)

Cross out c a t e g o r y not used
Circle selected category
C h o o s e suitable result

HTI

287

HOUSEHOLD
Now i would like some information about

NO"I

FAHIEY
USUAL RESIDENTS

'Lease give me the names
,f the persons who usually
i r e in your household,
t a r t ~ n g Nl¢h the head of
he household,

:I)

=rELATIONSHIP
TO HEAD OF
HOUSEHOLD
Uhet fS the

relationsh~p of
(}~AHE) to
the head of
the household? *

(2)

(3)

SEX

o~

M

o0

~

DE

~

07

~

FAMIL~ STATUS
FOR ALL PERSONS AGED H OR OLDER
qUNBE~ IN FAN.
I
Hes
Uhat i s the
IF AGE
Can
How old ~RITE
is
FANIL~
(NANE)
highest Lever

LESS
(NADE)
INAHE)? ~UHBEF FATHER-' ever
of school
THAN
read?
I~OTHER-~ been
(~AME)
25
CHILD -.~
£o
attended?
YEARS
schooL?
~hat i s the
is
IF COOE Z highest grade
(~ANE)
SKIP TO
(~AME)

s t i l l in
:OL* (11) completed at
school?
that level ?**
(8)
(9)
(10)
(11)
(5)
(6)
(7)
m l l ~
lllm
YES NO LEVEL GRADE YES
NO YES NO
YEARS

ICOUE

Is

(NANE)
male
or
Female?

(4)
M

,

E

,

E
1

1

F

~

~

~

1

~

1

E,E

1

~

1

E1E

2 I--I ~ 1

212

~

~

2

~DUCATION

AGE

~

~

~

,

1 ~

I~

E I ] D '
TICK HERE IF CONTINUATIO~ SREET USED [ ]
Just to make sure that ] hove a c ~ L e t e

NUHBER OF FAH[LY
List|ng:

1)

Are there any other persons such as small children or
i n f a n t s that we have not i i s t ~ ?

2)

Ave there any other people who may not be members of your famity~
l i k e servants, f r i e n d s , Lodgers, but who usually Live here?

3)

Are there any other guests oc v i s i t o r s who have been
tcf~berap{~y stayLng with you f o r the past 6 months or more?

4)

Are there any persons who usually Live here who have been awsy
f o r Less than 6 months?

5)

Are there any persons we have Listed who have been away f o r
the past s i x months?
* ) COOED FOR COLUHN (5)
RELATIONSRIP TO HEAD OF HOUSEHOLD:
01= HEAD
05=
02= WIFE OR HUSBAND
06=
03= SOD OR DAUGHTER
07=
04 = SON OR DAUGHTER*IN-LAW
08=

GRANDCHILD
PARENT
PARENT'IN'LAW
BROTHER OR SISTER

288

09= OTHER RELATIVE
10= ADOPTED/FOSTER CHILD
11= STEPCHILD
12= NOT RELATED
98= DODtT KNOW

,

+,E

21E

SCHEDULE
the people who usually live in your household.
PARENTAL SURVIVORSEIPAND RESIDENCE
FOR PERSONE LESS THAN 15 YEARS OLD

HARITAL
STATUS

IF ALIVE
Is (~AME)'S
natural
mother a(ive?

(12)
YES NO

Does (NAME)Is
natura( mother
Live in t h i s
household?

2

8

1

2

8

1

2

8

1

2

8

1

2

8

1

2

8

1

2

8

1

2

8

I

2

8

1

2

8

1

2

8

1

2

8

1

2

8

1

2

8

1

2

8

I

2

8

1

2

8

Has
(N/~E)
ever
been
married?

IF YES:
What Is his
nari~?

RECORh MhTHER'S
LINE NOHBER
(13)

RECORD FATBER~S
LINE NUMBER
(15)

(14)
YES NO

M
M
I-I-]
M
M
M
M
I-I-]
m
M
M
M
I-T]
I-I-1

AGE lh YEARS
AND ABOVE

ODeS (NAME)is
naturhl father
( l y e fn t h i s
household?

IF YES:
What Is her
name?

DK

1

Is (NAHE)~a
Natural
father alive?

(16)

DK

1

2

8

1

2

8

1

2

8

1

2

8

1

2

8

1

2

8

1

2

8

1

2

8

1

2

8

1

2

8

1

2

8

1

2

8

1

2

8

I

2

8

1

2

8

1

2

8

1

2

8

ELIGIBILITY

FhE &~DMEN

I f ALIVE

YES

M
M
M
M
M
M
M
M
FT7
M
M
M
M
M
M
M

CIRCLE LINE
NUMBER OF ALL
EVER'MARRIED
k~MEN AGE
15-49 FOE
INDIVIDUAL
INTERVIEW

(17)
Nh

1

2

01

1

2

h2

1

2

h3

1

2

04

1

2

h5

1

2

h6

1

2

07

1

2

08

1

2

09

1

2

lh

1

2

11

1

2

12

1

2

13

1

2

12

1

2

13

1

2

14

1

2

15

TOTAL NUMBEROF ELIGIBLE ~K~AEN I T
I I

YES E ~ - - ' ENTEREACHIN TABLE

NO D

YES D - - '

EW'EREADH'N TABLE

WO D

,EB D - - ,

ENT-- EACNIW TADLE

EO[~

VEB E]--,hBLETE N~EE ,E~ TAELE
* * ) CCOES FOR COLUMN (7)
LEVEL OF EhUCATION:
1: PRIMARY SCHOOL
E= JUNIOR HIGH BCNOOL
]= SENIOR HIGH BCEOGL
4= ACADEMY

EO []
5= UNIVERSITY
8= DON~T EWOW

GRADE:
7=CDMPLETED
8=DON~T KNO~

289

RTE

NO.
01

PERTANYAANDAN SARINGAN

I

KOOE

~hat i s t h e mai~ source oH d r i n k i n g water f o r menfoers

of your household?

PIPED INTO RESIDENCE. . . . . . . . . . .
PIPED INTO YARDOR PLOT. . . . . . . .
PUBLIC TAP. . . . . . . . . . . . . . . . . . . . .
PUMp. . . . . . . . . . . . . . . . . . . . . . . . . . .
PROTECTEDWELL. . . . . . . . . . . . . . . . .
UNPROTECTEDWELL. . . . . . . . . . . . . . .
PROTECTEDSPRING. . . . . . . . . . . . . . .
UNPROTECTEDSPRING. . . . . . . . . . . . .
RIVER. . . . . . . . . . . . . . . . . . . . . . . . . .

21
22
23
31
32
33

OTHER

96

TERUS
KE

I 1 ~

12~>13
13

RAINWATER
...................... 41

02

HOWtong does it take to go there, get water
and cof~e back?

(SPECIFY)

MINUTES. . . . . . . . . . . . . . . . .

F ~
I I I I

OR PREMISES. . . . . . . . . . . . . . . . . . .

996

03 Whatkind of toilet facility doesyourhouseholdhave? PRIVATEWITH
SEPTIC TANK. . . . . . . . . . . . . . . . . . .
PRIVATE WITH
NO SEPTIC TANK. . . . . . . . . . . . . . . .
SHARED/PUBLIC. . . . . . . . . . . . . . . . . .
RIVER. . . . . . . . . . . . . . . . . . . . . . . . . .

OTHER

I

oo

•>06 1
B

HOWfar is the distance between the weLL and the nearestJ
cessboot?

OISTANCE. . . . . . . . . . . .

(IN METER)

DON'T KNOW
................

I

Does your household have:

Does any memberof your household own:

I

A bicycle/rowboat?

A rnotorcycLe/raotorboat?
A ear?

J

MAIN MATERIALOF THE FLCOR

(RECORDOBSERVATION)

09

10

11

YES
BICYCLE/ROWBOAT. . . . . . . . . . 1
MOTORCYCLE/HOTORBOAT.....1
CAR. . . . . . . . . . . . . . . . . . . . . . 1

RO
2
2
2

DIRT/EARTH
BAMBOO. . . . ..........................................
~000 . . . . . . . . . . . . . . . . . . . . . . . . . . .
CONCRETE/BRICK. . . . . . . . . . . . . . . . .
TILE . . . . . . . . . . . . . . . . . . . . . . . . . . .
CERAMIC/MARBLE/GRANITE. . . . . . . . .

11
21

OTHER

96

22
31
32
33

(SPECIFY)

JAREA
................F .2

What is the floor area of your boitding?
(IN

98
NO

A television?
A gas stove?
A kerosene st~ve?
An electric stove?
A refrigerator?

I SO

METERS

1
I ELECTRICITY. . . . . . . . . . . . . . YES
RADIOOR TAPERECORDER...1
TELEVISION. . . . . . . . . . . . . . .
1
GAS STOVE. . . . . . . . . . . . . . . . 1
KEROSENESTOVE. . . . . . . . . . . 1
ELECTRIC STOVE. . . . . . . . . . .
1
.............
I
REFRIGERATOR

ELectricitY?
A radio o r tape recorder?

07

96

(SPECIFY)

OTHERCODES[ ~

V

06

12
21
31

CHECK15
WELL
(CODES21,22,23)

05

11

SQUAREMETERS)

DOR'T KNOW. . . . . . . . . . . . . . .

What iS the prin~ary construction n~terial of the outer
waLL?

What is the primary construction material of the roof?

J

I

BRICK. . . . . . . . . . . . . . . . . . . . . . . . .
WO(O . . . . . . . . . . . . . . . . . . . . . . . . . .
BAMBOO. . . . . . . . . . . . . . . . . . . . . . . . .

OTHER

(SPECIFY)

.......................
I CONCRETE
WC(JO. . . . . . . . . . . . . . . . . . . . . . . . . . .
TILE . . . . . . . . . . . . . . . . . . . . . . . . . . .

ASBESTOS/ZINC. . . . . . . . . . . . . . . . . .
LEAVES. . . . . . . . . . . . . . . . . . . . . . . . .
OTHER

998
1
2
]

6
01
OR
03
04
05
96

(SPECIFY)

12

What is the ownership status of your buiLding?

I CA4N
. . . . . .. . . . . . . . . . . . . . . . . . . . . . .
HORTGAGE

CONTRACT
.......................
RENT. . . . . . . . . . . . . . . . . . . . . . . . . . .
OFFICIAL. . . . . . . . . . . . . . . . . . . . . . .
OTHER
(SPECIFY)

011
02
03
04
05
96

RT3

290

971DHS
Logo

INDONESIA DEMOGRAPHIC AND HEALTH SURVEY 1997
INDIVIDUAL QUESTIONNAIRE
Confidential
IDENTIFICATION
i.

PROVINCE

.........................................................

5. REGENCY/i~JNICIPALITY *)
3.

CODE

...........................................

SUB-DISTRICT

4. V I L L A G E
5. A R E A . . . . . . . . . . . . . . .
6.

LARGE

CITY

7.

ENDMERATION

URBAN

-I/SM~LL
AREA

CITY

- I .......... RURAL
-2/TOWN

- 2 **)

-3/COUNTRYSIDE

-4*)

NUMBER

°9NOUSEEULD
EEEIDNE
SANPLECODEIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
.

LI.

LO. N A M E

OF

LINE

HOUSEHOLD

NUMBER

L2. N A M E

OF

HEAD

OF WOMAN

FROM

HOUSEHOLD

SCHEDULE ......................

WOMAN

I m ' r ~ q X ~%WER V I S I T S
3

FINAL

VISIT

DATE
INTERVIEW

D A T E .......
MONTH

INTERVIEWEE'S

NAME...

YEAR

[3.

9

9

7

I

. RESULT
NEXT

***)

***) . . . . . . . . . . . .

VISIT:

RESULT

E:::::::::::::::::::| F I N A L

RESULT

TIME

.....................T O T A L

NO.

CODES:

FIELD

*)
**)
***)

4

REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED

ii COMPLETED
2 NOT AT HOME
3 POSTPONED

I

INTERVIEWER

DATE

EDITOR

ISUPERVISOR
I
OFFICE

Cross out category not used
Circle selected category
Choose Suitable result

291

I

OF VISIT'

7 OTHER

EDITOR

CODE

KEYED

BY

CODE

.o,

I

QUESTIONS AND FILTERS

SKIP
I TO

COOING CATEGORIES

m

m
I

1011

RECORDTHE TIME,

I

102

F~rst I would l i k e to ask sor~e questions about you.
For most of the time u n t i l you were 12 years old, did
you L|ve in a ¢lty~ tn a tok11~ or In a viLLage?

CITY. . . . . . . . . . . . . . . . . . . . . . . . . . .
TOWN. . . . . . . . . . . . . . . . . . . . . . . . . . . .
VILLAGE. . . . . . . . . . . . . . . . . . . . . . . . .

I

::::::::::::::::::::::::::::

In whet month and year were you born?

105

I I
2
3

WRITE MOMTN IF HOT IN WESTERN CALENDAR
MONTH:

106

NOW old were you at your Last birthday?

AGE IN COUPLETED YEARS..,,.I

I

I

I J

I

CO'PARE AND CORRECT 105 ANt/OR 106 IF INCONSISTENT.

Are you now rimrried, divorced or widowed?

I0~

107

Nave you ever atterwJed school?

108

;that ts the highest level of school you attended:
prLmary, Junior high, senior high, acedemy~ or
untversfty?

I

109 I

I
110 I

1061

2
3

I

I

I

YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2-->114

PRIMARY. . . . . . . . . . . . . . . . . . . . . . . . .
JUNIOR HIGH SCHOOL. . . . . . . . . . . . . .
SENIOR HIGH SCHOOL. . . . . . . . . . . . . .
ACADEMY. . . . . . . . . . . . . . . . . . . . . . . . .
UNIVERSITY. . . . . . . . . . . . . . . . . . . . . .

1 I
2
3

|

4
E

I

ONOE......................... DI

What L$ the highest (GRADE, FORM~ YEAR) you cor~ptetnd
at that Level?
COMPLETED = 7
CHECK

I

MARRIED. . . . . . . . . . . . . . . . . . . . . . . . .
DIVORCED. . . . . . . . . . . . . . . . . . . . . . . .
WIDOWED. . . . . . . . . . . . . . . . . . . . . . . . .

[~

AGE LESS
THAH GE

AGE 25
OR ABOVE I

I

V
111

112

Are you c u r r e n t l y attending school?

YES. . . . . . . . . . . . . . . . . . . . . . . .

What wa~ the main reason you stopp¢~ attending school?

.,,.,

-->

NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Z

GOT PREGNANT. . . . . . . . . . . . . . . . . . . .
GOT MARRIES. . . . . . . . . . . . . . . . . . . . .
TO CANE FOR CHILDREN. . . . . . . . . . . .
FAMILY NEEDED HELP ON FARM

01
02
03

3

OR

IN BUSINESS. . . . . . . . . . . . . . . .
04
COULD NOT PAY SCNOOL FEES. . . . . . . 05
NEEDED TO EARN MOXEY. . . . . . . . . . . .
06
GRADUATED/HADENOUGH SCH~LING..O7
DID NOT PASS EXAMS. . . . . . . . . . . . . .
08
DID MOT LIEE SCH~L . . . . . . . . . . . . .
09
SCHOOL MOT ACCESSIBLE/TO0 FAR,,.lO
OTHER
96
(SPECIFY)
DK. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
98

113

CNECK 108:
[~

PNIV,J~RY

JUNIOR NIGH
OR HIGHER

>115

V
m

114

Can yOU read end understand a l e t t e r or newspaper
easfLy~ with d i f f i c u l t y , or not at e l l ?

292

I

I

EASILY. . . . . . . . . . . . . . . . . . . . . . . . . .
WITN DIFFICULTY. . . . . . . . . . . . . . . . .
HOT AT ALL . . . . . . . . . . . . . . . . . . . . . .

1
S
116

NO.
115

116

DO yOU UsuaLLy reed a newspaper o v magazine a t Least
or.co a week?

Do you usuaLLy l i s t e n t o a red~o e v e r y d a y ?

YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

NO,.,,. .........................

2

YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

NO. . . . . . . . . . . . . .

117

SKIP
TO

COOING CATEGORIES

QUESTIONS AND FILTERS

Do you uSuaLly ~atch t a t e v ~ s f o n a¢ l e a s t
once a ~eek?

..,***,,.,.**...2

YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

RO.,,,,,,.,.,.,,,,..,,........,,2

118

What v e L l g f o n are you?

MUSLIM. . . . . . . . . . . . . . . . . . . . . . . . . .

1

PROTESTANT/CHRISTIAN. . . . . . . . . . . .

Z

CATNOLIC. . . . . . . . . . . . . . . . . . . . . . . .

3

HINDU. . . . . . . . . . . . . . . . . . . . . . . . . . .

4

BUDDHIST. . . . . . . . . . . . . . . . . . . . . . . .

5

OTHER

6
{SPECIFY)

119

;,'hat Ls t h e Language used a t he,me?

INDONESIAN. . . . . . . . . . . . . . . . . . . . .

01-->201

JAVANESE. . . . . . . . . . . . . . . . . . . . . . .

OE

NUNDRNENE
......................

03

BATA[. . . . . . . . . . . . . . . . . . . . . . . . . .

04

HINARG. . . . . . . . . . . . . . . . . . . . . . . . .

05

EUGIREEE. . . . . . . . . . . . . . . . . . . . . . .

06

OTNHR

96
(SPECIFY)

120

Can you s p e a k Bahesa Indonesia?

YES................,............1

ZF INTERVIEW I $ IN BAHASA ZRDONESIA~DONIT ASKEO TH]~
QUESTIONS, CIRCLE CQOE 1.

NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

293

2

REPROOgCTIONI

I SECTION 2.

QUESTIORG AND FILTERS

NO.
201

202

203

ROW I WOutd t i k e to ask about a r t the births you have
had during your l~fe. Have you ever given birth?

204

205

207

NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

HOWmany sons Live wLth you?
AM how many daughters l i v e with you?

]

SONSAT HOHE. . . . . . . . . . . . . . .

DO you have any sons or daughters to whomyou have
given b i r t h who are a t t v e b u t d o ~ t Live with you?

How tony sons are a l i v e but do not t i r e wfth yOU?
Ar~dhowrt~iny daughters are aLivebut do not Hve with
you?

Have yc~Jever given b i r t h to a boy or a g i r t who was
born a l i v e but Later died? IF NO, PROBE: Any ~ b y
who cried or showed any sign of Life but survived
onty a few hours or days?

209

SUN ANSWERSTO 203, 2OSt ARD 2OZa AND ENTER TOTAL,

I|

1
->204

DAUGHTERSAT H~E . . . . . . . . . .

YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2--~206

SONSELSEWHERE. . . . . . . . . . . . .
DAUGHTERSELSEWHERE. . . . . . . .

YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2 - ->208

I TOTAL. . . . . . . . . . . . . . . . . . . . . .

[-~

I

NONE, ENTER tOOl.

CHECK208:

YES ~

1

I
I

NO ~

->206

]

Just tO make s u r e that I have t h i s r i g h t :
your l i f e , Is that correct?

2,0

I

;

I :ils°iii::ii:::iiiiiiii!

In alL, how many boys have die~fl?
Ard how many g i r t s have died?

IF

I
I
I

1

NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

I

IF NONE, ENTER tOOt.

208

I

I YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

IF NONEEBTER IOO*.
206

J YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Do you have any sons or daughters to whcm you have
given b i r t h who are now Living with you?

IF RONEt ENTER IOOI.

SKIP
TO

COOING CATEGORIES

i

yOU

have had in TOTAL -

-

I

Live births durLng

• PROBEAND
CORRECT 201-208 AS NECESSARY

V

EHEOR208

NOLVE

O~E OR HORE
LIVE BIRTH

BIRTHS
V

294

>223 I

211

NOW I ~outd L i k e t o record t h e names o f aLL your b i r t h s ,
one you had.
RECORDHARES OF ALL THE BIRTK$ IN 212.

•hether s t i L L a l i v e oP not~ s t a r t i n g

with the first

RECORDTWINS AND TRIPLETS ON SEPARATE LINES

5

295

CALCULATETHE DIFFERENCE BETWEEN THE YEAR OF INTERVIEW AND THE YEAR OF THE LAST BIRTH.
IF 4 YEARS OR HORE~ ASK: Were t h e r e any o t h e r L i v e b i r t h a f t e r (NAItE OF LAST CHILB)?

I YES. . . . . . . . . . . . . . . .

1

NO. . . . . . . . . . . . . . . . .

E

I

CC|4PARB 2S8 WITH NUHBEROF BIRTHS ABOVE AND HARK:
NUHSERS ~
ARE EA)4E L ~

NLG4SERSARE
BIFFBRENT

L---L-> (PROSE AND RECONCILE)

CHECK: FOE BACH LIVB BIRTH (,Q2151: YEAR OF BIRTH IS RECORDED
FOR EACH LIVING BIRTH (Q,217): CURRENTAGE ($ RECORDED
FOR BACH DEAD BIRTH (Q.219): AGE AT DEATH ]S RECORDED
FOR AGE AT DEATH 12 HONTH OR ONE YEAR ( Q , B I g ) : PROBE TO DBTBRHINE EXACT
NUBSER OF HONTHS

i -i EHECK
REooRSNo-RoFB,RTH$,NoE
B
RBCOBB"O".
ANoARY
-..RoSS,

296

D
[]

I

6

RO. I

OOEST,ONSANO,IL,ESS

I

SKIP

COOINGCATEGOR%ES

I TO
m
@

226

Are you pregnentnow?

YES.............................

f I
I

!
227

HOW many months pregnant are you?

HONTH......................

I

I

I

I I

I
ENTER tlHJl IS COLUH)I I OF CALENDARIN HONTflOF %UTERVIEWAND IN EACHPRECEDINGHONTHPREGNART I

228

229

pregnant then, dtd you went to waft u n t i l tate~,
or did you not want to become pregnant at all?

LATER. . . . . . . . . . . . . . . . . . . . . . . . . . .
NOT AT ALL. . . . . . . . . . . . . . . . . . . . . .

Have you ever had a pregnancy that mtscerrled~
wee el:or'~nd,or ended tn a stftlb|rth?

YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2
3

I
I
2--'-~235
I
1 |

NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

I

230 I Whendld the Last such pregnancy end?

I
231

CHECK230:
LAST PREGHA~CYENDED
SINCE JANUARY1992 [ ~

I

-BI

LAST PREGNANCYENDED
BEFOREJANUARY1992 1"--7

r

I

V

Have you ever had any other pregnancies which did not
result in a Live birth?

Hhen did your test ~netrual ~rled start?

1

BO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2y235

DAYS ASS. . . . . . . . . . . . . . . . .

1

WEEKSAGO. . . . . . . . . . . . . . . .

2

NONYHSAGO. . . . . . . . . . . . . . .

3

YEARSAGO. . . . . . . . . . . . . . . .

A

IN MENOPAUSE
..................

~A

BEFOREEAST PREGNAKCY
. . . . . . . . . 995
SEVERHENSTRUATSD
.............

297

I

YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2'4 I ASK FCADATEANDDURATIONOF ALL PREGNANCIESWNICHRESULTIN HISCARSIAGS,WAS ABORTEDOR
ENDEB I~ A STILLBIRTH SINCE JANUARY1989. ENTER"K" IN COLUHN1 OF CALENDARIN THE HONTH
THAT THE PREGNANCYTERHINATED
I AND "H" IN EACHPRECEDINGHONTHPRES~AHT.

235

>23g

996

I

I ,T,ECTION 3: KNOWLEDGEJ
301

PI~ECTICE

OF F I ~ I I L Y

|

P[..~.NMINGI

NOW I Would L f k e t o t a l k a b o u t f a m i l y p l a n n i n g - t h e v a r i o u s ways o r methods t h a t a c o u p l e can u s e t o
d e l a y , a v o i d o r end a p r e g n a n c y o r a b i r t h .
Wh(ch o f t h e s e ways o r methods have y o u h e a r d a b o u t ?
CIRCLE CODE 1 IN 302 FOE EACH METHOD ME#TIONED SPONTANEOUSLY.
THEN PROCEED DDWR THE COLUMN, READING THE NAi4E AND DESCRIPTION OF EACH HETHOD NOT MENTIONED SPONTANEOUSLY.
CIRCLE CODE 2 IF HETHO0 IS RECOGNIZED, AND CODE 3 I F NOT RECOGNIZED.
THEN, FOR EACH METHO0 WITH CODE 1 OR 2 CIRCLED IN 302, ASK 3D3"3OA BEFORE PROCEEDING TO THE NEXT HETHOD.

30} Have y o u e v e r

5oz Have y o u e v e r
h e a r d o f (METHOD)?

3o4 Where w o u l d y o u go t f
you w a n t e d t o use (METHOD)?

used (HETHOD)?

(USE COOES BELOW)*

READ DESCRIPTION OF
EACH METHOD.
11 P I L L "WCc0en c a n t a r e a p i l l
every day".

YES/SPONT . . . . . . . . . . . . . . . . . . .
YES/PROBED . . . . . . . . . . . . . . . . . .
NO. . . . . . . . . . . . . .

1
2

YES . . . . . . . . . . . . . . .

I

NO. . . . . . . . . . . . . . . .

2

OTHER

V
0_~ IOD "Wcrnen can h a v e a Loop or
c o i l p t a c n d I n s i d e them b y a
d o c t o r or a n u r s e " ,

YES/SPONT . . . . . .
YES/PROBED . . . . . . . . . . . . . . . . . .
NO. . . . . . . . . . . . .
• ............

S
3
V
1

INJECTIONS "WC~aen c a n h a v e an
YES/SPONT . . . . . . . . . . . . . . . . . . .
injection by a doctor
YES/PROBED . . . .
w h i c h s t o p s them f r o m beccming , NO. . . . . . . . . . . . . . . . . . . . . . . . . . . .
pregnant for several months".

YES . . . . . . . . . . . . . . .

I

NO. . . . . . . . . . . . . . . .

2

YES . . . . . . . . . . . . . . .

1

NO. . . . . . . . . . . . . . . .

E

III
OTHER

OTHER
V

O~

I NTRAVAG/D I APHRAGM/JELLY/FOAH
.Wor*en c a n p l a c e a t i s s u e o r a
d~aphragm o r cream f n t h e
vagina b e f o r e i n t e r c o u r s e " .

i

YES/SPONT . . . . . . . . . . . . . . . . . . . .
YES/PROBED....., . . . . . . . . . . . .

2

NO. . . . . . . . . . . . . . . . . . . . . . . . . .

3

YES . . . . . . . . . . . . . . .

1

NO. . . . . . . . . . . . . . . .

2

YES. . . . . . . . . . . . . . .

I

M
III

OTHER
v

51 COND~ "Hen can use a rubber
sheath d u r f n g sexual f n t e r course".

, YES/SPONT. . . . . . . . . . . . . . . . . . . . .
YES/PROBED
......
NO. . . . . . . . . . . . .
, ............

61 NORPLANT/IMPLAHT "Wocen can

, YES/SPONT. . . . . . . . . . . . . . . . . . . .

h a v e s m a l l rc~Js p u t i n t h e arm
to prevent pregnancy".

YES/
NO. . . . . . . . . . . . .

3
v

, ............

3

NO. . . . . . . . . . . . . . . .

2

I YES. . . . . . . . . . . . . . .

I

NO. . . . . . . . . . . . . . . .

2

,

OTHER
I

OTHER

III

V
0~

FEMALE STERILIZATION/TUBECTC~4Y
"Woolen c a n h a v e a n o p e r a t i o n
t O a v o i d h a v i n g a n y more
children".

08• HALE STERILIZATION/VASECTOMY
h a v e an operation t o
"Men can

a v o i d hav£ng a n y more
chi Ldren".

O•

PERIOOIC ABSTINENCE/CALENDAR
SYSTEH " C o u p l e s c a n a v o i d
h a v i n g s e x u a { i n t e r c o u r s e on
c e r t a i n d a y s o f t h e month when
t h e t~0alan I s more tlkely to
becc~e p r e g n a n t l %

, YES/SPONT . . . . . . . . . . . . . . . . . . . .
YES/PROBED . . . . . .
NO. . . . . . . . . . . . . . . . . . . . . . . . . .

,

Have y o u e v e r had an
operation to avoid
having anymore
children?
1
YES . . . . . . . . . . . . . . .
~0 . . . . . . . . . . . . . . . .
2

3

OTHER

v
YES/SPORT . . . . . . . . . . . . . . . . . . . .
YES/PROBED . . . . . . . . . . . . . . . . . .
NO. . . . . . . . . . . . . . .

Has y o u r husband
had an operation to
to a v o i d h a v i n g
chLldren?
YES . . . . . . . . . . . . . . .
1
NO. . . . . . . . . . . . . . . .
2

2
3

YES/SPDNT . . . . . . . . . . . . . . . . . . .
YES/PROBED . . . . . . . . . . . . . . . . . .
NO. . . . . . . . . . . . . . . . . . . .

1
2

3

YES . . . . . . . . . . . . . . .

1

NO. . . . . . . . . . . . . . . .

2

OTHER

Do you know where a p e r s o n
can o b t a i n a d v i c e o n how t o
use p e r i o d i c a b s t i n e n c e ?

OTHER

soceone do s o m e t h i n g ¢o end a
pregnancy".

NO. . . . . . . . . . . . . . .

V
1
2
3
v
1
2
3

OTHER HETHOO$? "Have y o u
12• hANY
e a r d o f a n y o t h e r ways o r

YES/SPORT . . . . . . . . . . . . . . . . . . .

1

NO. . . . . . . . . . . . . . . . .

3

"Men c a n be c a r e f u l
101WITHDRAWAL
and P U l l o u t b e f o r e c l i m a x " .
REGULATION
11• ABORTION/MENSTRUAL
" W ~ n c a n do something o r have

methods t h a t wccen o r men c a n
u s e t O a v o i d p r e g n a n c y ? ==.

M

YES/SPONT . . . . . . . . . . . . . . . . . . .
YES/PROBED . . . . . . . . . . . . . . . . . .
NO. . . . . . . . . . . . . . . . . .
YES/SPORT . . . . . . . . . . . . . . . . . . .
YES/PROBED. . . . . . . . . . . . . . . . . .

YES . . . . . . . . . . . . . . .

1

NO. . . . . . . . . . . . . . . .

2

YES . . . . . . . . . . . . . . .

1

NO. . . . . . . . . . . . . . . .

2

OTHER

M
fll

v
* C ~ E S FOR 30A
GOVERN~HT
HOSP[TAL . . . . . . . . . . . . . . . . . . .
HEALTH CENTER. . . . . . . . . . . . . .
FP FIELDk~ORKEE. . . . . . . . . . . . .
FP HOBILE UNIT. . . . . . . . . . . . .

(SPECIFY)
2

CHECK 302:
(SPECIFY)

YES . . . . . . . . . . . . . . .
NO. . . . . . . . . . . . . . . .

1
2

YES . . . . . . . . . . . . . . .
NO. . . . . . . . . . . . . . . .

1
2

YES . . . . . . . . . . . . . . .
EO. . . . . . . . . . . . . . . .

1
2

IS THERE CODE 1 OR
3
(SPECIFY)

YES

NO

i

OTHER

PR|VATE

11
12
13
14

15

(SPECIFY)

HOSPITAL . . . . . . . . . . . . . . . . . . .
FP CL1NID . . . . . . . . . . . . . . . . . .
DOCTOR. . . . . . . . . . . . . . . . . . . . .
MIDWIFE. . . . . . . . . . . . . . . . . . . .

21
22
23
24

PHARMACY/DRUGSTORE. . . . . . . . .

25

OTHER

26
(SPECIFY)

GO TO 303

305

CHECK 3 0 3 :

NOT A SIEBLE "YES"
(NEVER USED)

~
~
V

OTHER
DELIVERY POST . . . . . . . . . . . . . .
HEALTH POST . . . . . . . . . . . . . . . .
FP POST . . . . . . . . . . . . . . . . . . . .
TRADITIONAL HEALER . . . . . . . . .
FRIENDS/RELATIVES . . . . . . . . . .
OTHER
(SPECIFY)
DONtT KNOW. . . . . . . . . . . . . . . . .

I

I

AT LEAST OEE "YES"
(EVER USED)

298

~

• SKIP TO 308

31
32
33
34
35
96
98

NO.
3S6

SKIP
I TO

CO01NE CATEGORIES

QUESTIONS ARD FILTERS
Have you ever usod anyth{ng or t r I o d ~n any way to
delay or avofd g e t t i n g pregnant?

YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1 |

NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2 I

30?

I

306A I

ENTER "0" IN COLUMN | OF CALENDAR IN EACH ELANK MONTH-

307

What have you used or done? (SPECIFY)

~330B

CORRECT 303-305 (AND ASK 302 IF NECESSARY)
(SPECIFY)
NOW I woutd (ike to ask you about the f ~ r s t time that
you did socething or used a method to delay a pregnancy
or avoid g e t t i n g p r e g n a n t ?

308

What is the f i r s t thing you ever did or method you
ever usod to delay or avoid getting pregnant?

]

PILL . . . . . . . . . . . . . . . . . . . . . . . . . . . .
011
]UD . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
02
(EJECTIONS. . . . . . . . . . . . . . . . . . . . . .
03
IHPLANTS/NORPLANT. . . . . . . . . . . . . . .
04
INTRAVAG/DIAPHRAGH/FOAM/JELLY...O5
COEDOtl. . . . . . . . . . . . . . . . . . . . . . . . . .
06
FEMALE STERILIZATION . . . . . . . . . . . .
07
HALE STERILIZATION. . . . . . . . . . . . . .
O0
PER]OOIC ABSTINENCE. . . . . . . . . . . . .
09
WITHDRAWAL . . . . . . . . . . . . . . . . . . . . . .
OTHER
91 ~

>308B

(SPECIFY)
308A

Where did you go to get t h i s method the f i r s t

time?

GOVERI~EMT
HOSPITAL. . . . . . . . . . . . . . . . . . . . . . .
HEALTH CENTER. . . . . . . . . . . . . . . . . .
FP FIELD~ORNER. . . . . . . . . . . . . . . . .
FP MOBILE UNIT . . . . . . . . . . . . . . . . .
OTHER
(SPECIFY)
PRIVATE
HOSPITAL. . . . . . . . . . . . . . . . . . . . . . .
fP CLINIC . . . . . . . . . . . . . . . . . . . . . .
DOCTOR. . . . . . . . . . . . . . . . . . . . . . . . .
MIDWIFE. . . . . . . . . . . . . . . . . . . . . . . .

12
13
IA
15

21
22
23

24
PHARHACY/DRUGSTORE ............. 25

OTHER
(SPECIFY)
OTHER
DELIVERY POST. . . . . . . . . . . . . . . . . .
HEALTH POST. . . . . . . . . . . . . . . . . . . .
FP POST. . . . . . . . . . . . . . . . . . . . . . . .
TRADITIONAL HEALER. . . . . . . . . . . . .
FRIENDS/RELATIVES. . . . . . . . . . . . . .
OTHER
(SPECIFY)
OOHIT EEG~. . . . . . . . . . . . . . . . . . . . .
3SaB|

309

r

How many I f v f n g children did you have at that time,
i f anY?

NUMBER OF CHILDREN. . . . . . . . .

26
31
32
33
34
35
96
98

~-~

IF NONE, ENTER '00 f .
CHECK303 ITEM 07
1~4AN NOT
STERILIZED 9

IAOHAN
STERILIZED [ ~

>312A

V
CHECK226:

310

NOT PREGNANT 9
OR UNSURE

PREGNANT

>328

CHECK lSdA:
CURRENTLY HARRIED9

311 |

I

DIVORCED/
WIDOWED [ ~

Are you c u r r e n t l y doing sCtllething or using any method
to delay or avoid getting pregnant?

312

Which method are you usLng?

312A

CIRCLE IO7S FOR FEMALE STERILIZATION.

YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1 I

No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2-->3306

PILL . . . . . . . . . . . . . . . . . . . . . . . . . . .
01 I
IUD. . . . . . . . . . . . . . . . . . . . . . . . . . . .
02-->317
INJECTIONS. . . . . . . . . . . . . . . . . . . . .
03.--~>31dH
IHPLANT/NORPLANT. . . . . . . . . . . . . . .
04-->317
INTRAVAG/DIAPHRAGN/FOAH/JELLY..05-->317
CONDOH. . . . . . . . . . . . . . . . . . . . . . . . .
06~>316N
fEHALE STERILIZATION . . . . . . . . . . .
07
HALE STERILIZATION . . . . . . . . . . . . .
08----L>317
PERIOOIC ABSTIEERCE. . . . . . . . . . . .
09
OTHERWITHDRAW.A.L. . . . . . . . . . . . . . . . . . .
906~10 >328
(SPECIFY)

299

I

HO, J

SKiP
I TO

COOING CATEGOR(ES

QUESTLOIIS AND FILTERS

m

315A~ At the tfme you f i r a t started using the p f t t , did you
I consult a doctor or a midwife?

YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1J

I

DK...........HH.....H....**H*8

I

315B~ Do you have a package of p i t t = in the house?

I
315Cl

I

1

Ep2 oNE EO;

k~y donlt you have a package of piLLs In
the house?

3''A

RAN OUT. . . . . . . . . . . . . . . . . . . . . . . . . . .
COST TOO NUDE. . . . . . . . . . . . . . . . . . . . .
HUSBANDAWAY. . . . . . . . . . . . . . . . . . . . . .
HAS PER(CO. . . . . . . . . . . . . . . . . . . . . . . .
OTHER
(SPEC|FY)

1
2"~
~>3160

I

PILLS HISSING IN ORDER. . . . . . . . . . . .
- - > 3 6E
PILLS HISSING GOT OF ORDER. . . . . . . . 2
NO PILLS HISSING. . . . . . . . . . . . . . . . . .
3

/

31dEJ Why is i t that you have not taken the
I p i t t = ( t n order)?

DOESN'T KGOWWHAT TO DO. . . . . . . . . . .
HEALTH REASONS. . . . . . . . . . . . . . . . . . . .
FOLLOWING FP FIELDWORHERZE
INSTRUCTION. . . . . . . . . . . . . . . . . . . . . .
HEW PACKET. . . . . . . . . . . . . . . . . . . . . . . .
HENSTRUATING. . . . . . . . . . . . . . . . . . . . . .
OTHER
(SPECIFY)

SCOWBRAND CHART FOR PILLS:
PLease t e l l me which of these Is the
brand of piLLs that you are us|ng.

1Z--

>316E

3-A-S-6--

BEARD HAHE:
DOESN'T KNOU. . . . . . . . . . . . . . . . . . . . .

(RECORD NAHE OF BRAND)
316E

I
I

|
2---->316

PACKAGE SEEN. . . . . . . . . . . . . . . . . . . . .

Please show me the package of p i l l s you
are now uatng.

316.1I ADEECK
RACNETFORPILLUSEANORARK
CORRECT CGOE.

31(£

1

NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(RECORD NAHE OF BRAND)
316

YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

When was the Last ttme you took a p i l l ?

98

DAYS AGO:
HORE THAN ONE HORTNAGO. . . . . . . . . 97

316F

CHECK 316E:
MORE THAR TWO DAYE
AGO

T~)DAYS AGO OR
LESS
[--1

~
V

.317 I

316~ ;Nly arenft you taking the p i t t these days?

HUSBANDAWAY. . . . . . . . . . . . . . . . . . . . . .
FORGOT. . . . . . . . . . . . . . . . . . . . . . . . . . . .
HEALTH REASONS. . . . . . . . . . . . . . . . . . . .
COST TOO NUDE. . . . . . . . . . . . . . . . . . . . .
NO NEED TO TAKE DAILY. . . . . . . . . . . . .
RAN OUT. . . . . . . . . . . . . . . . . . . . . . . . . . .
HAS PER(GO. . . . . . . . . . . . . . . . . . . . . . . .
OTHER
(SPECIFY)

316~ When dtd you test have an injection?

NUNTHEAGO.. . . . . . . . . . . . . . . .

3161

~ 1

CHECK 316E:
RORE THAN THREE HOMTNE
AGO V ~ ]

316d

ODE-0~--"
04~
05-->317
06-DE-96"

LESsTHREEHONTHSAGO OR [-'7

Why haven't you had an Injection recentLY?

!>317 I

HUSBANDAWAY. . . . . . . . . . . . . . . . . . . . . . .
FORGOT. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HEALTH REASONS. . . . . . . . . . . . . . . . . . . . .
CDST TOO HIJCH
OTHER
(SPECZFY)

1
317

. . . . . . . . . . . . . . . . . . . . . .

I

10

300

NO.
316K

316L

SKIP

COOINGCATEGORIES

QUESTIORS AND FILTERS

J TO

Ptease show me the package of condom
that your husband Is using,

BRAND NAKE:

~-1~>317

(RECORD NAHE OF BRAND)

NOT ABLE TO SNOW. . . . . . . . . . . . .

....98

Why cant( you show me the package of
c o n d ~ that your husband is uBfng?

HUgRAND KEEPS. . . . . . . . . . . . . . . . . . . . .
RAg OUT. . . . . . . . . . . . . . . . . . . . . . . . . . .
OTHER
(SPECIFY)

316~

SN(~ BRAND CHART FOR CONDORS:
PLease teLL r~ whfch of these fs the
brand of condoms that your husband is using.

317

Bow much does (dtd) i t cost you f o r :

J

I

1I
2

6

I

~4ETfloo

COSE(Bp): I I I I I I I I

1 cycle (packet) of p{LLs
the ]UD
--an

injection

--

the in~otant/Norp(ant

FREE METHCO. . . . . . . . . . . . . .

9999995

--

i n t r avag/di aphragm/f oarn/j e LLy

PACKAGE. . . . . . . . . . . . . . . . . .

9999994

a package of condccls (contains 3 pfeces)
the s t e r i l i z a t i o n

SERVICE

opera(fan

COBE(Ro) I I I I I I I I

Now r~ch was the service and r e g i s t r a t i o n feel I f any?

FREE SERVICE. . . . . . . . . . . . .

9999996

FREE HETHOO AND SERVICE,.999999? - DONJT KNOW. . . . . . . . . . . . . . .

999~8

317A1

In obtaining (METHOO) did you pay s i t , p a r t , or nothln

YE$~ ALL . . . . . . . . . . . . . . . . . . . . . . . .
YES, PART. . . . . . . . . . . . . . . . . . . . . . .
NOTH(NG. . . . . . . . . . . . . . . . . . . . . . . . .
DORIT KNOW. . . . . . . . . . . . . . . . . . . . . .

317A2

Who paid f o r the f a m i l y ptanntng method you are using?

CORPANY/ASURARCE. . . . . . . . . . . . . . . .
OFFICE. . . . . . . . . . . . . . . . . . . . . . . . . .
FAHILY. . . . . . . . . . . . . . . . . . . . . . . . . .
OTHER
(SPECIFY)
DORIT KNOW. . . . . . . . . . . . . . . . . . . . . .

317B

1

CHECK 312:

h17CI

CHECK 312:

317c

--.>3178
1-->317B
2 I
3 I
8------->3178
1

2
3

6

8

]

PILL . . . . . . . . . . . . . . . . . . . . . . . . . . .
01
J
lUg . . . . . . . . . . . . . . . . . . . . . . . . . . . .
02
IXJECTIOE$. . . . . . . . . . . . . . . . . . . . .
03
IHPLABT/NORPLANT. . . . . . . . . . . . . . .
04
INFRAVAG/DIAPHRAOR/FOAH/JELLY..O5
CO~DOM. . . . . . . . . . . . . . . . . . . . . . . . .
06
FEHALE BTERZLZZATZOR. . . . . . . . . . .
07
HALE STERILIZATION . . . . . . . . . . . . .
O~'-'-J*>B17E

CIRCLE FOg HETHOO:

In xhat rconth and year dfd you obtain (HETH(~O) the Last
t f~ne?

I~PLANT/NORPLART

I

OTHER

1989

CHECK 317C:

SINCE JANUARY

BEFORE JABUARY 1989

11

301

NO,
317C3

SKIP
TO !

COOING CATEGORIES

QUESTIONS AND FILTERS
Why d i d you not obtain another impLant/Rorplant?

MEROPAUEE. . . . . . . . . . . . . . . . . . . . . .
HUSBARD AWAY. . . . . . . . . . . . . . . . . . .
AFRAID. . . . . . . . . . . . . . . . . . . . . . . . .
FORGOT. . . . . . . . . . . . . . . . . . . . . . . . .
NOT FOUND. . . . . . . . . . . . . . . . . . . . . .
COST l ~ H
..................
AVAILABILITY . . . . . . . . . . . . . . . . . . .
OTHER
(SPECIFY)
DON'T KNOW
. . . . . . . . . . . . . . . . . . . . .

Where did you obtain (METHOD) the Last time?

3170

RECORD NAME OF METRO0 SOURCE, PROBE TYPE OF METHOD
SCURCE AND CIRCLE CORRECT COOE.

O1
OR
03
04
03
06
07
96
98

80VERNXER~
HOSPITAL. . . . . . . . . . . . . . . . . . . . . . .
HEALTH CENTER. . . . . . . . . . . . . . . . . .
FP FIELDW~)RKER. . . . . . • . . . . . . . . . .
FP MOBILE UNIT . . . . . . . . . . . . . . . . .

11
12
13
14

OTHER

15
(SPECIFY)

PRIVATE

HOSPITAL. . . . . . . . . . . . . . . . . . . . . . .
FP CLINIC . . . . . . . . . . . . . . . . . . . . . .
DOCTOR. . . . . . . . . . . . . . . . . . . . . . . . .
MIDWIFE. . . . . . . . . . . . . . . . . . . . . . . .
PHARMACY/DRUGSTORE. . . . . . . . . . . . .
OTHER
(SPECIFY)

(NAME OF PLACE)

OTHER
DELIVERY POST. . . . . . . . . . . . . . . . . .
HEALTH POST. . . . . . . . . . . . . . . . . . . .
FP POST. . . . . . . . . . . . . . . . . . . . . . . .
TRADITIOWAL REALER. . . . . . . . . . . . .
FRIENDS/RELATIVES. . . . . . . . . . . . . .
OTHER
(SPECIFY)
DONJT KNOW. . . . . . . . . . . . . . . . . . . . .

What is the 0w~in reason you decided to use
(OWRREBT METHOD IN 312) rather than some other
methods of f a m i l y pLannfng?

317E

21
22
23
24
25
26

31
32
33
34
33

96
98

RECOHMENDATIONOF
FAMILY PLANRING~OWKER. . . . . . . . 01
RECOHMENDATIONOF
FRIENDS/RELATIVES. . . . . . . . . . . . .
02
SIDE EFFECTS OF OTHER METHODS..O3

CONVENIENCE. . . . . . . . . . . . . . . . . . . .
04
ACCESS/AVAILABILITY . . . . . . . . . . . . OH
LOWER COST. . . . . . . . . . . . . . . . . . . . .
06
WANTED PERMANENTMETHO0. . . . . . . . 07
HUSBAND PREFERRED. . . . . . . . . . . . . .
O8
WANTED MORE EFFECTIVE METHO0...09
OTHER
96
(SPECIFY)
98
DONtT KNOW. . . . . . . . . . . . . . . . . . . . .

317F

Are you having any heaLth problems in using
(CURRENT METHOD IN 312)?

317G

What is the r0ain health problem
(CURRENT METHOD IN 312)?

YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2

WEIGHT GAIN. . . . . . . . . . . . . . . . . . . .
WEIGHT LOSS. . . . . . . . . . . . . . . . . . . .

BLEEDING. . . . . . . . . . . . . . . . . . . . . . .
HYPERTENSION. . . . . . . . . . . . . . . . . . .
HEADACHE. . . . . . . . . . . . . . . . . . . . . . .
QUEASY. . . . . . . . . . . . . . . . . . . . . . . . .
AMENORRHEA. . . . . . . . . . . . . . . . . . . . .
WEAK/TIREO. . . . . . . . . . . . . . . . . . . . .

OTHER
(SPECIFY)
DON*T KNOW. . . . . . . . . . . . . . . . . . . . .

317H

Are you hav(n9 any other problems in using
(CURRENT METHO0 IN 312)?

I

317I I

01
OR
03
04
05
06
07
OB

96
98

YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2-- ->317J

HUSBAND DISAPPROVES. . . . . . . . . . . .
01
ACCESSIBILITY/AVAILABILITY,,,..O2
COST TOO MUCH. . . . . . . . . . . . . . . . . .
03
INCONVENIENT TO USE. . . . . . . . . . . .
04
STERILIZED, BUT WANTS CHILDREN,E5
OTHER
96
(SPECIFY)
DON'T KNOW. . . . . . . . . . . . . . . . . . . . .
98

What is the ri~in problem?

I
317J I

>317H

CHECK312 AND 312A:RESPONDENT/HUSBAND[~STERILIZED

NEITHER STERILIZED

V-7
>323 I

V

302

12

NO.
318

Where did the s t e r i l i z a t i o n

SKIP
~ TO

CODING CATEGORIES

QUESTIONS ANG FILTERS
take place?

krRITE THE N/U4E OF PLACE. PROBE TO IDENTIFY
THE TYPE OF PLACE AND CIRCLE THE APPROPRIATECOOE.

HEALTH CENTER. . . . . . . . . . . . . . . . . . .
PRIVATE HOSPITAL. . . . . . . . . . . . . . . .
PRIVATE CLINIC . . . . . . . . . . . . . . . . . .
PRIVATE DOCTOR. . . . . . . . . . . . . . . . . .
OTHER
(SPECIFY)

12
21
2R
23
96

OUN~T KNOW. . . . . . . . . . . . . . . . . . . . . .

98

(NAME OF PLACE)
319

DO you regret that (YOU/YOUR HUSBAND) had the operation | YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
not to have any (nlore) children?
I| NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

,20

Why do (YOU/YOUR HUSBAND) regret the operation?

321

322

In what r~wanth and year was the s t e r i l i z a t i o n

CHECK: 321
STERILIZED BEFORE
JANUARY 1~2

1
2-->32

I RESPONDENTWANTSANOTHER C H I L D . . . . 1 1
HUSBAND WANTSANOTHER CBILD. . . . . . . 2
SIDE EFFECTS. . . . . . . . . . . . . . . . . . . . . .
3

perforced?

CHILD DIED. . . . . . . . . . . . . . . . . . . . . . . .

4

OTHER

6

MONTHy.E..A..R.......................... . . . . . . .

9

STERILIZED SINCE 9
JANUARY 1992

ENTER C~OE FOR STERILIZATION (COOE 7 OR 8)
IN MONTH OF INTERVIEW IN COLUMN 1 OF THE
CALENDAR AND ERCN MONTH BACK TO JANUARY |98G'

ENTER COOE FOR STERILIZATION (COUE 7 OR
8)

IN MONTHOF INTERVIEWOF THE CALENDAR

ANO I~ EACH t4GHTHBACK r o THE DATE OF

THE OPERATION
I

323

PeopLe select the place where they get family piercing
services f o r various reasons. The place selected
may be more convenient Or give better services or is
cheaper.
In your case, what was the main reason you went to the
place you did rather than to some other places?
RECORD RESPONSEAND CIRCLE CODE.

Any other reasons?
RECORD RESPONSEAND CIRCLE COOE.

MAIN OTHEI
REASON REASOI
ACCESS-RELATED REASONS
CLOSER TO HONE. . . . . . . . . . 01
CLOSER TO WORK... . . . . . . . 02
AVAILABILITY OF
TRANSPORT. . . . . . . . . . . . . .
03
LO~GER HOURS OF
OF OPERATIO~. . . . . . . . . . .
04
USE OTHER SERVICES
AT THE FACILITY. . . . . . . . 05
SERVICE-RELATED REASONS
STAFF MORE COMPETENT/
FRIENDLY. . . . . . . . . . . . . . .
06
CLEANER. . . . . . . . . . . . . . . . .
07
OFFERS MORE PRIVAGY.....OB
SHDRTERWAITING TIHE....O9
LOWER COST. . . . . . . . . . . . . . .
10
WANTED ANONYHITY. . . . . . . . . 11
OTHER
96
(SPECIFY)
WO OTHER REASON. . . . . . . . . . . . . . . . .
OTHER
(SPECIFY)
DON'T KROW . . . . . . . . . . . . . . .
98

328

Between the f i r s t day of a wo~an,s period and the f i s r t YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
day of her nee~=xtpericd, are there certain times when she NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
has a greater chance of becoming pregnantthan other
DONJT KN(~J. . . . . . . . . . . . . . . . . . . . . . .
times?

328A

During which times of the monthly cycle does a wc~an
have the greatest chance of becomfng pregnant?

r

RgA1

O1
02
0'
04

OS
06
07
08
09
10
11
12
9&

1
2
3--,-J->']OA

I

DURING HER PERICO. . . . . . . . . . . . . . . . .
1|
RIGHT AFTER HER PERIOD
HAS ENDED. . . . . . . . . . . . . . . . . . . . . . . .
2
IN THE MIDDLE OF TNE CYCLE. . . . . . . . S
JUST BEFORE HER PERIDO BEGLNS,....4
OTHER
6
(SPECIFY)
O0 N i T K N ~ . . . . . . . . . . . . . . . . . . . . . . . .
8

OTHER

CHECK512:
PERIODIC ABSTINENCE
OR WITHDRAWAL
E~

I S,Oi

METNOOS

32~B

DO you abstain f r c ~ sex on days when you are c e r t a i n
that you have a greater chance of becc~ing pregnant?

328C

How do you determine which days of your monthly
cycle not to have sexual relations?

I

iZ:::i:::ii:i::iiiiiii::::iiil/IssoA
EASED ON CALENDAR. . . . . . . . . . . . . . .
BASED ON BODY TEMPERATURE. . . . . . .
BASED ON CERVICAL MUCUS
(BILLINGS METBOU). . . . . . . . . . . . .
BASED O~ BODY TEMPERATURE
AND CERVICAL MUCUS. . . . . . . . . . . .
OTHER

1 |
R
3

NO SPECIFIC SYSTEM. . . . . . . . . . . . . .

8

4
6

3O3
13

I

NO. I

QUESTIONS AND FILTERS

I

SKIP
TO

COOING CATEGORIES

m

330A|

330B

I

ENTER METHO0 COOE FROfl 312 IN CURRENT ItONTH IN COLUMN 1 OF CALENDAR, THEN DETERMINE WHEN
SHE STARTED USING THIS METHO0 THIS TIRE. ENTER METNO0 COOE IN EACH MONTE OF USE.
ILLUSTRATIVE DUSSTIONE;
- When did you s t a r t using t h l a method continuously?
- How Long have you been using t h l a method continuously?
I WouLd t(ke to aak seem questions apeut aLL of the methods you used to avoid g e t t i n g
pregnant in the fast f i v e years,

USE CALENDARTO PROBE FOR EARLIER PERIOOS OF USE AND NONUSE, STARTING WITH MOST RESENT
USE~ BACK TO JANUARY 1989.
USE ELAHESOF CMILDREM, DMEE OF BIRTH, AND PERICOE OF PREGNANCYAS REFERE~tCE POINTS,
IN EACH MONTH, ENTER COOE FOR METHO0 OR "0" FOR NONUSE IN COLUMM 1. IR COLUMN2,
ENTER C00ES FOR DISCONTINUATION NEXT TO LAST EONTE OF USE.
NUMBER OF COOES ENTERED IN COLUMN 2 MUST BE THE SAME AS
TEE NUMBEROF INTERRUPTIONSOF CONTRACEPTIVEUSE IN COLUMN I .
ASK WHY SEE STOPPED USING THE METHO0. IF A PREGNANCYFOLLOWED, ASK WESTEES SHE
BECAME PREGNANTUNINTENTIONALLY WHILE USING THE METEQO OR DELIBERATELY STOPPED
TO GET PREGNANT.
ILLUSTRATIVE GUESTIONS:
COLUMN 1 :
-When was the Last time you used a method? Which method was that?
-When did you s t a r t using that method? How tong a f t e r the b i r t h of (NAHE)?
-flow tong did you use the method then?
COLUMN 2:
"Why did you stop using the (METHOD)?
-Did you pecome pregnant while using (METEOO), or did you stop to get pregnant,
or stop f o r some other reason?
IF DELIBERATELY STOPPED TO BECOME PREGNANT, ASK:
"HOW many months did Lt take you to get pregnant a f t e r you stopped using (METHO0)?
ENTER "0" IN EACH SUCH MONTH IM COLUMN 1.
3DOC

Did you attend the group which are f a m i l y planning
group?

YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2--->330D

330C1 What fs the name of group which you attend the Last t(ce?
NAME
330c2

When did the teat time you attend a meeting of that
group?

I

(SPECIFY)

r
~
MONTH. . . . . . . . . . . . . . . . . . . . . . .

I

I

YEAR. . . . . . . . . . . . . . . . . .
330C3 Does the group coLLect ~ n e y f o r use i n the famiLy

pLanning a c t i v l t l e a ?
330D

Have you ever seen a sign or heard about BLue CircLe?

YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

I |
2 I

YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DON'T KROW. . . . . . . . . . . . . . . . . . . . . . .

1 |
2
e~-mL>33OE

330D1 Can you teLL me what f t Is?

PRIVATE FAMILY PLANNING SERVICE..1 1
OTHER
2
(SPECIFY)
DON~T KNOW. . . . . . . . . . . . . . . . . . . . . . .
O

330E

YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Have you ever seen a sign or heard about Golden Circle?

NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DONIT KROW
.......................

330E1

Can you teLL me what i t is?

CEECK 226:
PREGNANT~

OTHER

NOT PREGNANTOR
UNSURE

YES...........

...................

NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Nave you contacted/ever
been contacted by a f a m i l y
planning worker during the
s i x months before you
became pregnant?
331A

CHECK 226:PREGNANT~

Have you ever vJsttod
a health f a c t t t t y duping
the s i x months before you
became pregnant?

~-L>331

PRIVATE FAMILY PLANNING SERVICE,,1

(SPECIFY)
DONIT KNOU. . . . . . . . . . . . . . . . . . . . . . .
331

I

1 I
2

B

8
1

2

Have you contacted/ever
been contacted by a
f a m i l y planning worker
during the past s i x
s i x months?
UNSUREPREGNANT
SOT
OR

YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1 I

NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2-->332

YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1 |
2

1 m

I

I

Have you ever v i a | t e d
a health f a c { L I t y d u r f n g
the past s i x months?

3318

Old anyone at the health f a c i l i t y
f a m i l y planning methods?

332 |

Do you t h i n k that breaatfedfng can a f f e c t a woman,s
chance of becoming pregnant?

YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DONIT KNOW. . . . . . . . . . . . . . . . . . . . . . .

3

DO you th(nk a womanls chance of becsm(ng pregnant is
(pereasod, decreased, o r not affected?

INCREASED........................
DECREASED........................

I |
2

I
332A|

I

speak to you about

NOT AFFECT. . . . . . . . . . . . . . . . . . . . . . .
DEPENDS. . . . . . . . . . . . . . . . . . . . . . . . . .
OODIT KNOW. . . . . . . . . . . . . . . . . . . . . . .

3O4

I

2-->335

3

4

|

I

8---->335

14

SKIP

335

335A

m
335B

CHECK 106A:

J>ss7

DI VORCED/['--1

CHECK 312:
NOT ASKEO/NOT
USINg A NOOERN
METHO0
m
V

CURRENTLYUSING
A HETHO0
>337
mmm

~

Whet I g t h e matn reason you are not using
a c o n t r a c e p t i v e method t o avoid pregnancy?
Any o t h e r reasons?
RECORD MAIN AND OTRER REASON I N SEPARATE COLUNNS.

MAIN OTHER
REASON REASON
LACK OF 104OWLEDGE
DONIT KNOWNETHO0. . . . . . . . 01
01
OONIT KNOWSOURCE. . . . . . . . OS
02
OPPO~ITI~TOUSE
RESPONDENT OPPOSEO. . . . . . . 03
03
HUSBAND OPPOSED. . . . . . . . . . 04
04
OTHERS OPPOSED. . . . . . . . . . .
03
03
RELIGIOUS PROHIBITION,,,,O6
06
FERTILITY'RELATED REASONS
>337
NENOPAUEAL/HYETSRSCTOHY,,O~'---"O-J~
SUBFECUND/INFECUNO. . . . . . . 00
08
POSTPARTUH/OREASTTEEOINE,09
09
INFREQUENT SEX. . . . . . . . . . .
10
10
WANT CHILDREN. . . . . . . . . . . .
11
11
NET~-RELATED REASOflS
HEALTH CONCERNS. . . . . . . . . .
12
12
PEAR OF RIDE EFFECTS.,...13
13
LACK OF ACCESS/TOOFAR...1A
1A
COST TOO MUCH. . . . . . . . . . . .
IS
15
16
INCONVENIENT TO USE . . . . . . 16
GAIN/LOSE WEIGHT. . . . . . . . .
17
17
PREGNANT. . . . . . . . . . . . . . . . . .
18
18
19
NO OTHER REASON. . . . . . . . . . . . . . . . .
OTHER
96
(SPECIFY)
OTHER
,96
(SPECIFY)
DONIT KNOW. . . . . . . . . . . . . . .
98

336A

0o you i n t e n d t o use e f e m i t y planning m t h ~ to detay
o r avoid pregnancy W i t h i n the n e x t 12 months?

YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DON'T KNOW. . . . . . . . . . . . . . . . . . . . . .

1-->336c
2 I
8

336B

Do you i n t e n d t o use a f a m i l y planning method t o de(ay
o r avoid pregnancy a t any t f ~ i n t h e f u t u r e ?

YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1 =
E -->33~
8 -->337

336C

Whenyou use a method, which ¢ethod Would you
p r e f e r t o use?

NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DON*T KNOW. . . . . . . . . . . . . . . . . . . . . .

I

I

PILL . . . . . . . . . . . . . . . . . . . . . . . . . . .
01 J
IUD. . . . . . . . . . . . . . . . . . . . . . . . . . . .
02
INJECTIONS. . . . . . . . . . . . . . . . . . . . .
03
IHPLANT/NORPLANT. . . . . . . . . . . . . . .
04
IHTRAVAG/OIAPHRAGH/FOAH/JELLY..05
CONDOH. . . . . . . . . . . . . . . . . . . . . . . . .
06
FEMALE STERILIZATION. . . . . . . . . . .
07
MALE STERILIZATIO~ . . . . . . . . . . . . .
SO
PERIOOIC ABSTINENCE. . . . . . . . . . . .
09--'-1
WITHDRAWAL . . . . . . . . . . . . . . . . . . . . .
1
OTHER
9
337

UNSUR~9
S36C1

Where w i l l you go t o o b t a i n the (HETHOO)?

GOVERNNEMT
HOSPITAL. . . . . . . . . . . . . . . . . . . . . . .
HEALTH CENTER. . . . . . . . . . . . . . . . . .
FP FIELOWORKER. . . . . .